Materials for Review

The items below are not required. If you do have this information, please enter it below.

Slides

Path Number

# of slides

Check if MSK can retain slide

Slide 1 - Path Number

Slide 1 - Number of slides

Slide 1 - Retain slides

Slide 2 - Path Number

Slide 2 - Number of slides

Slide 2 - Retain slides

Slide 3 - Path Number

Slide 3 - Number of slides

Slide 3 - Retain slides

Slide 4 - Path Number

Slide 4 - Number of slides

Slide 4 - Retain slides

Blocks

Path Number

# of blocks

Check if MSK can retain block

Block 1 - Path Number

Block 1 - Number of blocks

Block 1 - Retain blocks

Block 2 - Path Number

Block 2 - Number of blocks

Block 2 - Retain blocks

Block 3 - Path Number

Block 3 - Number of blocks

Block 3 - Retain blocks

Block 4 - Path Number

Block 4 - Number of blocks

Block 4 - Retain blocks

Other

Check if MSK can retain other

Other 1 - Path Number

Other 1 - Retain other

Other 2 - Path Number

Other 2 - Retain other

Billing Information

What entity should be billed for charges incurred?

Referring Physician

Patient

Patient's Insurance Carrier

Direct Patient Billing (e-check or credit card)

The minimum charge for a pathology consultation is $450. Any additional testing that is necessary to render a diagnosis (including immunohistochemistry stains) will be charged in addition to this fee. MSK will bill either your insurance or the patient / consult requestor directly. Please verify that MSK accepts your insurance by calling 646-227-3228.

If patient's insurance carrier is being billed, please provide:

Subscriber NameSubscriber Name

Relationship to SubscriberRelationship to Subscriber

Insurance Carrier NameInsurance Carrier Name

Policy NumberPolicy Number

Group NumberGroup Number

If the patient's insurance carrier denies payment, who will be responsible for unpaid services?

Referring Physician

Patient

Has the patient been made aware of this referral to MSK?

Yes

No

Has the patient been made aware of the possibility of costs affiliated with these services?

Yes

No

For Medical Insurance Billing Only, is patient currently undergoing an inpatient hospital stay?

For Adult PatientsMinus iconIcon indicating subtraction, or that the element can be closed.Plus IconIcon indicating addition, or that the element can be opened.Arrow (down) icon.An arrow icon, usually indicating that the containing element can be opened and closed.

For Child & Teen PatientsMinus iconIcon indicating subtraction, or that the element can be closed.Plus IconIcon indicating addition, or that the element can be opened.Arrow (down) icon.An arrow icon, usually indicating that the containing element can be opened and closed.

For Healthcare ProfessionalsMinus iconIcon indicating subtraction, or that the element can be closed.Plus IconIcon indicating addition, or that the element can be opened.Arrow (down) icon.An arrow icon, usually indicating that the containing element can be opened and closed.

For Research ScientistsMinus iconIcon indicating subtraction, or that the element can be closed.Plus IconIcon indicating addition, or that the element can be opened.Arrow (down) icon.An arrow icon, usually indicating that the containing element can be opened and closed.